Eating Chocolate and other lessons from the ABIM Forum

19082013

Every year, the ABIM Foundation convenes a set of thought leaders on American health care to answer the tough questions. At first glance, this year’s meeting had the same standard agenda – talks and discussions followed by networking and informal activities. However, for some reason, this Forum was more exhausting. Perhaps trying to solve the nation’s vexing problems facing health care is fatiguing! So, what were some of the themes that we came away with?

Intrinsic motivation is powerful, so can we create it? We heard about the potential dangers of extrinsic motivation through financial reward. Pay-for-performance, after all, is a tool that is only as good as the system is designed, and many designs have not been very effective. I was reminded of an unusual medical education experiment when they started paying residents in pediatrics on a fee-for-service model (yes, residents). The residents saw more patients, and their outcomes even improved with fewer ER visits! But, closer inspection yielded that these residents stacked their clinics with well child visits, who were healthier and did not need to visit the ER. So fee-for-service residency was abandoned. While everyone agreed it was time to move away from fee-for-service medicine, do we really think a change in the payment system creates intrinsic motivation? One health system offered their solution: recruit those that are intrinsically motivated. But, that still leaves us with how does one become intrinsically motivated? The answer likely lies in the last session of the meeting –find and cultivate joy in work. After all, if the work of transformation is enjoyable, people will do it for free. And for physicians, joy does not come from lowering the GDP, but from treating the patient in front of you.

A series of small innovations add up to a larger one. There were a series of innovators highlighted at the meeting who shared their innovation. While many were sharing large-scale innovations and initiatives like ACGME’s CLER Program, I shared a much smaller scale innovation, a redesigned resident clinic handoff using ideas generated from talking with over 100 patients about their experience. I certainly recognized the scale I was operating on was much smaller than some of the other folks in the room who lead large health plans or organizations. Then, one of the speakers who transformed their culture highlighted that it was a series of small innovations adding up to the larger one that made it doable. Featuring innovations at this meeting is not new, but the discussion of scalability was important. As each innovation was discussed, the question became how was this scalable and could be spread to others. This discussion was particularly salient to our Teaching Value Project team as we hosted a breakfast to not only introduce the project, but also discuss the future and how to spread this innovation…so stay tuned.

Organizational culture and leadership matters… a lot. While on the subject of necessary ingredients for innovation, the terms organization and leadership would probably be the biggest if we did a word cloud of what people said at this meeting. It can feel trite, but it’s true…leadership and culture are key. The type of leadership that was highlighted focused on nurturing innovators and supporting people in the work that they do. While they are not afraid to take risks, they are also understand their frontline clinicians and patients. Too bad they also sounded like an endangered species. Not surprisingly, many groups had the same action item – train visionary leaders to lead these healthcare systems of the future. While we can wait for the new visionary leader to be manufactured, culture always halts people in their tracks. How do you create the culture you want? The recurring theme here was to make sure you had good people. In other words, recruit people for the culture you want, not the on you have. And for a real change, a more radical business approach would be to let go of the “protectionist mentality” where everyone is going to keep their job. Moving to a results-oriented work environment would mean not only recruiting the right people but getting rid of the wrong people. I’m not so sure our academic health systems are ready to do this, but it was refreshing to hear from a business leader that term limits and succession planning were the norm. In this way, organizations are automatically refreshed with new ideas from leaders who were prepared to lead.

Eating radishes when you want to eat chocolate is work. To summarize, forcing people to exert willpower to resist what they want to do (eat chocolate) by doing something else (eating radishes) translates into hard work to resist, and less patience for something else. A more complete explanation of this study is here. Sure, this sounds simple, but we do keep piling quality measures and requirements on every physician in the context of a 15 minute office visit. Unfortunately, electronic health records are forcing us to eat more radishes, and this comes at the expense of talking to patients. At least two innovators solved this problem by having someone else eat the radishes, such as a scribe in primary care so that physicians could focus on the joy, spending more time with patients.

Ask patients to help design the solution. While this may sound like a no brainer, its not as easy as it sounds! This is an unusually high level of patient engagement that most of our organizations are not used to. In one stunning example, a hospital in Sweden redesigned its dialysis center so patients can swipe in whenever they want and self-administer their dialysis. In the innovation I presented, we asked 100 patients in our resident clinic what would make their clinic handoff go smoother when they transitioned PCP’s when their residents graduated. The answers led us to interventions that we never would have thought of, like honoring the patients with a certificate to recognize their teaching efforts of our residents and a cartoon to facilitate patients learning how the process of the handover occurs and what they should do.

So, what does this mean for future doctors? Well, it starts with recruiting intrinsically motivated individuals and training them to be healthcare leaders who can learn to work alongside patients to generate small innovations that can add up to larger organizational transformation. And let them eat chocolate … so they too can find the joy in their work.